Basic Information
| Provider Information | |||||||||
| NPI: | 1194056598 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALLEY VISTA CARE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VISTA THERAPY OF SANDPOINT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 220 S DIVISION AVE | ||||||||
| Address2: | |||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838641759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082454576 | ||||||||
| FaxNumber: | 2082452138 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 S DIVISION AVE | ||||||||
| Address2: | |||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838641759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082454576 | ||||||||
| FaxNumber: | 2082452138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2010 | ||||||||
| LastUpdateDate: | 01/25/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BORGMAN | ||||||||
| AuthorizedOfficialFirstName: | KASEY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 2082454576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | ID | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.